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Factors affecting survival after ruptured abdominal aortic aneurysm
Factors affecting survival after ruptured abdominal aortic ancurysm M a g r u d e r C. Donaldson, M.D., joel M. Rosenberg, M.D., and Charles A. Bucknam, M.D., Hartford, Conn. To identify the factors affecting the high mortality rates associated with ruptured abdominal aortic aneurysm (AAA), a review was made of the records of 81 patients treated surgically between 1972 and 1983. Correlation of data with survival and predictive value of preoperative findings were studied. The mortality rate was 43.2%; there was a 29.2% mortality rate among those surviving the day of surgery. Patient-determined variables associated with deaths included age more than 76 years, hematocrit less than 30% and acute abnormality detected by ECG at admission, and suprarenal extension or free rupture of the AAA. Survival could be predicted with only 70% accuracy with a computerized discriminant function based on age and hematocrit and blood pressure values determined at admission. Events following admission associated with death were precipitous fall or persistently low level of preoperative blood pressure, technical complications, and postoperative organ failure. Although the patient's ultimate outcome after ruptured AAA is partly determined before intervention of the physician, efforts to address events resulting in death after admission by improving rapid diagnosis, early resuscitation, and prompt flawless surgery can increase survival. (J VAse SURa 1985; 2:564-70.)
Rupture o f an abdominal aortic aneurysm (AAA) is a catastrophic event that without direct surgical intervention almost always results in death. Even with surgery the mortality rate remains disconcertingly high despite advances in technique, materials, and perioperative care since report o f the first successful repair o f a ruptured AAA in 19545 In the hope o f improving outcome after rupture many authors have attempted to delineate the crucial factors that affect morbidity and mortality rates. We have reviewed a consecutive series o f patients to characterize the hospital course and to identify the influence o f certain patient-determined and physician-determined variables on outcome. METHODS All patients who were operated on at Hartford Hospital between 1972 and 1983 and who were found to have a ruptured AAA were retrospectively reviewed. Rupture was defined as a defect in the aneurysmal wall that had allowed the extravasation o f a quantity o f blood. Patients who had surgery without evidence o f extravascutar hematoma and paFrom the Departments of Surgery, Hartford Hospital and the University of Connecticut School of Medicine. Reprint requests: M. C. Donaldson, M.D., Department of Surgery, University of Connecticut Health Center, Farmington, CT 06032. 564
tients who were not subjected to laparotomy for symptomatic aneurysms were excluded. Among a total o f 557 patients who underwent resection o f AAA during this period, 81 patients with proven rupture were studied. Nine staff surgeons contributed patients to this series, ranging in number contributed from one to 20. The statistical significance o f data correlations was evaluated with the chi-square test, and the predictive value o f preoperative findings was assessed by discriminant analysis. RESULTS H o s p i t a l course. The mean age o f the 81 patients treated between 1972 and 1983 was 70.5 y e a r s (range 52 to 92 years); the group consisted o f 65 men and 16 women. Associated problems included hypertension (42%), significant pulmonary disease (25%), and symptomatic coronary artery disease (23%). T w o patients had been subjected to laparotomy for other reasons less than 3 weeks before AAA rupture. At admission all but three patients (96.3%) complained o f pain; 70% had some form o f back pain and 58% abdominal pain (Table I). Fainting (30%) and vomiting (22%) were also prominent. Physical examination at admission revealed a palpable mass in 91%, abdominal tenderness in 78%, and a mean systolic blood pressure o f 91 m m Hg. Laboratory studies done prior to surgery showed a mean
Volume 2 Number 4 July 1985
Survival after ruptured abdominal aortic aneurysm
.'able I. Symptoms and findings at admission (n = 8 1 ) * Symptoms Pain Abdominal Back Fainting Vomiting Findings Mass Tenderness Blood pressure <80 mm Hg Hematocrit <38% White blood cell count > 10,000/~1 AAA seen on abdominal x-ray film
96.3158.0 70.4 29.6 22.2 91.3 77.5 41.7 42.2 79.4 74.4
*Number represents patients in the study. ~-Percentage of patients.
Table II. Preoperative blood pressure trend and operative mortality data (n = 79)* Blood pressure at administration of anesthetic >100 mm Hg <100 mm Hg
Blood pressure at admission >100 mm Hg
<100 mm Hg
Group A 18 Patients 3 (16.7%) Died Group C 6 Patients 6 (100%) Died
Group B 14 Patients 4 (28.6%) Died Group D 41 Patients 22 (53.7%) Died
*Incomplete data on two patients.
hematocrit value of 37.8% and a mean leukocyte count of 13,914/~1. A plain radiograph of the abaomen was taken in 43 patients; results were positive tor AAA in 74%. Other positive diagnostic tests included ultrasound (10), angiography (5), and peritoneal tap (1). A mean o f 31.6 hours elapsed from the time of onset of symptoms to admission to the emergency department; 31% of patients presented in 2 hours or less. Median time between admission to the hospital and entrance into the operating suite was 6.1 hours. Within 40 minutes of entering the operating room, aortic control had been obtained in half the patients. The preoperative blood pressure trend, divided into four categories, is demonstrated in Table II. Mean systolic pressure when anesthetic was administered was 91 mm Hg; in seven patients no pressure was obtainable. The mean time for surgery was 3.9 hours. Only three of the 81 ruptured aneurysms extended above the renal arteries. Thirteen patients
565
Table III. Pcriopcrative patient-determined variables (n = 81) Age* (yr) Mean Range
70.5 52-92
Sex (no.) Male Female Medical history Symptomatic heart disease Hypertension Symptomatic lung disease Peripheral vascular disease Renal insufficiency Hospital admission Mean time from symptom onset to emergency department admission (hr) Systolic blood pressure (rnm Hg) Mean Range Hematocrit* Mean Range White blood cell count Mean Range ECG changes* Operative findings Mean aneurysm size (cm) Aneurysm location (no.) Infrarenal Suprarenal Rupture site (no.) Retroperitoneal Intraperitoneal
65 16 23.0% 42.0% 25.0% 8.8% 1.2% 31.6
91.0 0-230 37.8% 24%-52% 13,914/Ixl 6000-23,000/ixl 16.1% 8.5 78 3* 71 10"
*Significant correlation with death (p < 0.06) with age >76 yr and hematocrit <30%.
(16%) were found to have an associated unruptured iliac aneurysm. Ten patients (12%) were found to have free intraperitoneal rupture and 71 had a contained retroperitoneal hematoma. Vascular control was achieved in the majority (76%) by clamping below the renal arteries but 19 patients (24%) needed suprarenal aortic occlusion for variable time intervals (mean 26 minutes). Dacron grafts (60% woven, 40% knitted) were used for all 81 patients with a sleeve graft in 31 and aortoiliac or aortofemoral bifurcation grafts in the remainder. Heparin was used almost invariably, either systemically or infused into the distal arterial tree after aortic control was achieved. Twenty-five technical complications including venous, splenic, or intestinal injury and peripheral embolization occurred in 22 patients (27%), resulting in reoperation in eight and associated with death in 13 (59.1%). Intraoperative deaths occurred in 12
Journal of VASCULAR SURGERY
566 Donaldson, Rosenberg, and Bucknam
T a b l e IV. Perioperative physician-determined variables (n = 81)
Variable
Time course Emergency department to operating room .(hr) Median Range Operating room to aortic clamping (mm) Mean Range Duration of surgery (hr) Mean Range Operative course Systolic blood pressure (mm Hg) At anesthetic administration Mean Range At aortic clamping Mean Range Suprarenal clamping (No. of patients) Duration of suprarenal clamping (min) Mean Range Technical complications* (No. of patients) Urine output~ (nil) Mean Range Total fluids at operation (ml) Mean Range Total amount of blood transfused (units) Mean Temperature of patients when leaving surgery (°F) Mean Range Administration of pressors in recovery departments (No. of patients)
Table V. Postoperative course (n = 81)
6.1 20 min to 96 hr 50.8 10-270 3.9 1-8
91.3 0-200 101.2 0-210 19 (23.5%) 26 5-75 22 (27.2%) 510 " 0-1900 7710 3200-14,000 11.1 94.6 86-100 16 (23.5%)
*Significant correlation with mortality (p < 0.05). tFourteen patients were anuric. instances (15%) with four additional deaths within the first few hours after the patients reached the recovery room. The average fluid requirement during surgery was 7.7 liters and 29% o f the patients required more than 10 liters. The mean transfusion requirement was 11.1 units and 25% o f patients needed 15 or more units o f packed cells or whole blood. The average intraoperative urine output was 510 ml; urine output was 200 ml or less in 32% of patients, and 17% were anuric. In the recovery r o o m 40% o f patients were given diuretics whereas 24% needed pressor agents. The most c o m m o n postoperative complications among the 65 patients surviving at least 1 day after
Died day of surgery Survived day of surgery ECG changes Amylase elevation Bilirubin elevations Serum creatinine elevations Ischemia of the colons Tracheal intubation >3 days* Ileus >5 days* Dialysis* Patient stay Intensive care unit (mean days) Hospital (mean days) Survived past first day after surgery Overall survival
No. ofpatients (%) 16 (19.7) 65 (80.2) 13 (20.0) 12 (18.5) 14 (21.5) 29 (44.6) 7 (10.8) 27 (41.5) 28 (43.0) 18 (27.6) 5.4 (range 0-48) 20.1 (range 0-81) 46/65 (70.7) 46/81 (56.7)
*Significant correlation with mortality (p < 0.05).
;~
surgery were tracheal intubation for more than 3 days (41%), serum creatinine elevation (45%), renal failure requiring dialysis (28%), and ileus for more than 5 days (43%). N e w cardiac ischemia or arrhythmia occurred in 20%, hyperbilirubinemia in 21%, and hyperamylasemia in 18%. Ischemia o f the colon became manifest in seven patients (11%). The length o f stay in the hospital averaged 20.1 days a m o n g the patients who survived the day o f surgery, with an average o f 5.4 days in the intensive care trait. Total hospital stay was not significantly different between patients w h o were eventually discharged and those who died. Days spent in the intensive care unit by survivors were less than half that by nonsurvivors (4.15 vs. 10.75 days). The overall mortality rate was 43.3% for the entire group o f 8J, patients and 29.3% for the 65 w h o survived the day o f surgery. Correlative analysis. Facts describing the hos- , pital course wcrc divided into two major categories depending on whether they were determined prior to medical intervention or were to some degree under the control o f physicians (Tables I I I and IV). Patientdetermined factors tested and found to correlate statistically with eventual death were age more than 76 years, hematocrit less than 30% and presence o f electrocardiographic instability at admission, and the finding ofsuprarenal extension or free peritoneal rupture o f the AAA. Neither history o f prior cardiorespiratory or renal disease nor preoperative elevations in serum creatinine or urea nitrogen could be asso- . ciated with outcome. Regarding variables under some degree o f control ,
Volume 2 Number 4 July 1985
Survival after ruptured abdominal aortic aneurysm 567
.'able VI. Surgery for abdominal aortic aneurysm 1957-1980 Interval
Unruptured (% mortality)
Ruptured (% mortality)
Total (% mortality)
1957-1971 1972-1983 Total
183 (4.9) 476 (5.0) 659 (5.0)
74 (47.3) 81 (43.2) 155 (45.2)
257 (17.1) 557 (11.1) 814 (11.8)
by the physician, a significant correlation was found between mortality rate and preoperative blood pressure trend (Table II). When systolic blood pressure could be maintained at or increased to 100 mm H g prior to the administration of anesthetic (groups A and B), there was improved survival. The presence of persistent hypotension (group D) was not so om;'lous as a downward trend in pressure (group C), which was associated with a 100% mortality rate. Time between entering the operating room and aortic clamping averaged 20 minutes in this unfortunate group, appropriately shorter than that time in all other groups. Eight of the 10 vascular, intestinal, and splenic injuries inflicted during surgery occurred in the groups who remained hypotcnsive or became hypotcnsive preoperatively. Total duration of time with blood pressure less than 100 mm H g correlated significantly with outcome. Patients in an unstable condition, defined as those who arrived at the hospital with a blood pressure less than 100 mm H g and a hematocrit less than 35%, were not taken to the operating room any sooner than ones in a stable condition, defined as those with pressures over 100 mm H g and hematocrit more than 35%. Patients in an unstable condition experienced "aore than twice the overall mortality rate (54.5%) than those in stable condition (22.2%). Patients in an unstable condition who wcrc delayed more than 30 minutes before entering the operating room experienced a 6 8 % (13 of 19) mortality rate, as opposed to a 16% (one of six) mortality rate if surgery was possible within 30 minutes of admission. In the operating room a significantly higher mortality rate was associated with technical complications, including venous, intestinal, or splenic injury and peripheral embolization. All other intraoperativc parameters were not statistically important to survival. Postoperative use of pressor agents, tracheal intubation for more than 3 days, ileus for more than 5 days, bilirubin and serum creatinine elevation, and use of dialysis all correlated statistically with mortality rates (Table V). Six of the seven patients in whom
ischemia of the colon became evident after surgery died despite an aggressive reoperative policy. These postoperative morbid events were generally consequences of the combined insults of AAA rupture and surgery, and not independent risk factors. In an effort to predict outcome from preoperative patient status, discriminant analysis was performed with patient-determined factors evident at admission to the hospital. Age was the most important discriminant of survival, followed by hematocrit and blood pressure values at admission. Combined weighting of these three factors provided accurate prediction of outcome 70% of the time. DISCUSSION Overall mortality rates after surgery to treat ruptured AAA have decreased only modestly during past years. From 1957 to 1971 the survival rate at Hartford Hospital was 52.7%, 2 compared with 56.7% between 1972 and 1983 (Table V1). Except in a few reports, a-s other series have shown a similar relative stagnation of progress, 6qa all the more striking in view of the low mortality rates of 0% to 4.2% reported for elective AAA resection. 1°-14In addition to these elective resections, our mortality rate of 5.0% includes those patients exhibiting symptoms and undergoing surgery on an emergency basis who were found at operation not to have AAA rupture. Clearly, efforts to detect and treat AAAs before catastrophe must be maintained and expanded. An aggressive elective policy is justifiable for elderly patients who have a good prognosis despite the presence of an aneurysm as well as for younger patients with relatively small AAAs (i.e., 4 tO 5 cm). Once the AAA has ruptured, the surgical team is placed at a tactical disadvantage, trying to control a lethal disease process often already well advanced by the time the patient enters the hospital. Indeed, eventual outcome after surgery is strongly tied to factors determined before medical intervention. Age of the patient and hematocrit and blood pressure values present at admission heavily influenced subsequent events in the hospital in our series. These data pre-
568 Donaldson, Rosenberg, and Bucknam
dicted outcome with 70% accuracy for any given patient by a computer-derived discriminant algorithm. Although these variables are important to survival, their predictability is not precise enough for such a statistical formula to be applicable in medical triage. The most crucial step determined by the physician in therapy for ruptured AAA is definitive control of ongoing or recurrent blood loss through the aneurysm wall. Although many patients who survive to reach the hospital have a contained retroperitoneal hematoma that is relatively stable, the likelihood of a sudden increase in bleeding with deepening hypvolemia is totally unpredictable. In our series all patients who were in stable condition initially and who experienced a precipitous drop in blood pressure from rapid bleeding died. Patients whose pressures could be maintained or raised to a level more than 100 mm H g did relatively well and were presumably not bleeding or were bleeding at very slow rates during the immediate preoperative period. Even patients in whom hypotension at admission could not be corrected prior to surgery, presumably with moderate ongoing bleeding, fared better than those patients in stable condition initially who suddenly deteriorated. Because of the unpredictability of continued leaking, undue delay before surgical intervention can be expected to increase the chance of having to operate urgently under suboptimal technical conditions to control sudden hemodynamic deterioration; some of our patients might have survived with more prompt surgery. The patient's stable condition is not a reason to relax; once the diagnosis seems clear and resuscitation has been initiated, the operating room team should move, regardless of whether the patient is still hypotensive. Fifty-five of our patients entered the hospital in a hypotensive state, and 41 of them were still hypotensive at the time of administration of anesthetic despite preoperative efforts to improve their blood volume status. The duration of hypotension correlated significantly with outcome with the criterion of 100 mm H g or less to define the hypotensive group. A better indication of the adequacy of peripheral peffusion, such as pH, might be a more useful predictor of outcome than blood pressure. It is probable, although undocumented by our series, that blood volume repletion sufficient to raise blood pressure to normal levels will precipitate recurrent bleeding, and that stable relative hypotension with improved perfusion should be the modest goal of preoperative fluid resuscitation efforts. Ultimate con-
Journal of VASCULAR SURGERY
trol can occur only with aortic clamping, and fluk, I resuscitation must be regarded as a most tenuous adjunct as the diagnosis is being established and the surgical team is being mobilized. It was surprising to us to find unexpectedly prolonged time intervals between admission of the patient to the hospital and transport to the operating room. Some of this time was spent confirming the diagnosis, without which timely and useful intervention is impossible. A number of patients in our series undoubtedly suffered from either misdiagnosis or delayed diagnosis. The clinical picture can be misleading, and the classic triad of sudden severe back or abdominal pain, tender pulsatile abdominal mass, and hypotension was present in only 47% of our patients at admission. Atypical pain in the hip, groin, or thigh might occur. Hypotension is often abser" '~ and a mass or tenderness may not be readily detectable, particularly in an unresponsive subject. The presence of any part of the classic triad should be sufficient reason to assume a ruptured AAA may be present until proven otherwise, especially in a patient with a known previous aneurysm. Simple radiographs, ultrasound, and/or CT scans are rapid and often fruitful objective tests to confirm the presence of an AAA, with extramural rupture sometimes evident. However, prompt surgical exploration should not be delayed in order to pursue additional diagnostic workup; once the diagnosis is even suspected, mobilization of the operating team should be started. In a comparison of the four patient groups categorized according to the preoperative blood pressure course, there was no difference in time between admission and transport to the operating room. However, there was an appropriate decrease in tim ~, before aortic clamping in the two groups with hypotension at the time of anesthctic administration. These two groups had the highest technical complication and mortality rates. Technical complications, including venous, intestinal, and splenic injury and embolization, correlated significantly with survival for the entire series. O f i9 patients who died in the postoperative period, 13 (68%) had suffered a technical complication, whereas such mishaps occurred in only seven (15 %) of the 46 eventual survivors. It is reasonable to assume that technical complications may have contributed independently to the mortality rate and that it might be possible for physicians to reduce deaths by working to reduce the complication rate. A higher incidence of complications found in pa-
Volume 2 Number 4 July 1985
" dents who were hypotensive at the time of administration of anesthetic and in whom there is a necessity for rapid and sometimes less precise aortic exposure and control suggests that obtaining aortic occlusion by alternate swift and atraumatic means might be fruitful. Others have recommended temporary thoracic aortic clamping via a left thoracotomy, supraceliac clamping through the gastrohepatic ligament, or balloon occlusion via a peripheral artery. 4,1s Blunt suprarenal compression with a fist or occluding device5 may also allow more careful dissection of the aneurysm neck as may low incision of the aneurysm with introduction of an occluding balloon to effect control before mobilizing the duodenum and left renal vein) 6 Because temporary suprarenal clamping by any technique may increase .~orbidity and mortality rates, it should probably be reserved for patients who arc in an unstable condition and in whom the risk of visceral injury during hasty infrarenal aortic clamping is judged to be high. There are clearly enough options available to provide rapid aortic control without inflicting mortal damage to important structures. Peripheral thromboembolization occurred in 11 patients. It was recognized and treated at the time of aneurysm repair in eight instances with four deaths (50%) and treated by repeat surgery later in three instances with two associated deaths (67%). It may be possible to avoid emboli by careful handling of the aneurysm and application of distal clamps first where possible, ~7 and to minimize the effects of emboli by routine use of balloon thromboembolectomy through the distal anastomosis at the time of aneurysm repair. Heparin was used almost invariably after ~ortic control had been obtained. Ischemia of the colon was recognized in seven patients during the early postoperative period, with six associated deaths (86%). It is unclear how many of these patients suffered a temporary ischemic insult during the period of preoperative hypotension and aortic cross-clamping and how many lost arterial supply as a result of aneurysm resection) 8 Eventual death aftcr surgery correlated statistically with each indication of organ failure, as expected, 19 except for elcvation of serum amylase. It is interesting that the number of days spent in intensive car~: for nonsurvivors was more than twice that for survivors, which is only one index of the greater costs associated with patients who eventually died. The course of the 19 deaths during the postoperative period was largely determined by preoperative events,
Survival after ruptured abdominal aortic aneurysm 569
and aggressive supportive measures were only partly capable of improving the outcome. Although the opportunities for saving lives are probably less in the postoperative phase than in any other stage of the disease, efforts to detect and treat complications of rupture and surgery undoubtedly made a difference to some patients. This series has again demonstrated the undesirability of being forced to treat an AAA after it has ruptured rather than electively. Although much of the eventual outcome after rupture may be determined by factors out of the physician's control, there are a number of points of impact in which additional effort might be rewarded. Early diagnosis during the initial fluid resuscitation followed by prompt, technically flawless aortic repair are the goals of management. Thirty years after the first repair of a ruptured AAA, these goals remain elusive and additional progress can be expected only with continued attempts to analyze and improve current practice. REFERENCES 1. Gerbode F. Ruptured aortic aneurysm--a surgical emergency. Surg Gynecol Obstet 1954; 98:759. 2. Bucknam CA, Deren MM, Donovan TJ, Low HBG. Abdominal aortic aneurysms at Hartford Hospital 1956-1971. Hartford Hosp Bull 1972; 27:124-8. 3. Lawrie GM, Morris }'r GC, Crawford ES, Howell JF~ Whisennand HH, Badami JP, Storey SS, Starr DS. Improved resuits of operation for ruptured abdominal aortic aneurysms. Surgery 1979; 85:483-8. 4. Lawrie GM, Crawford ES, Morris GC, Howell JF. Progress in the treatment of ruptured abdominal aortic aneurysms. World J Surg 1980; 4:653-60. 5. Mulherin JL, Edwards WH. Improved survival after ruptured abdominal aortic aneurysm. South Med J 1980; 73:986-9. 6. Gaylis H, Kessler E. Ruptured aortic aneurysms. Surgery 1980; 87:300-4. 7. Ottinger LW. Ruptured arteriosclerotic aneurysms of the abdominal aorta. JAMA 1975; 233:147-50. 8. Hoffman M, Avellone JC, Plecha FR, Rhodes RS, Donovan DL, Beven EG, DePalma RG, Frisch IA. Operation for ruptured abdominal aortic aneurysms: A community-wide expericnce. Surgery 1982; 91:597-602. 9. Shumacker HB, Barnes DL, King H. Ruptured abdominal aortic aneurysms. Ann Surg 1973; 177:772-9. 10. Hicks GL, Easdand MW, DeWeese JA, May AG, Rob CG. Survival improvement following aortic aneurysm repair. Ann Surg 1975; 181:863-9. 11. Crawford ES, Saleh SA, Babb JW, Glacser DH, Vaccaro PS, Silvers A. Infrarenal abdominal aortic aneurysm--factors influencing survival after operation performed over a 25-year period. Ann Surg 1981; 193:699-708. 12. Soreide O, Lillestol J, Christensen O, Grimsgaard C, Myhre HO, Solheim K, Trippestad A. Abdominal aortic aneurysms: Survival analysis of four hundred thirty-four patients. Surgery 1982; 91:]88-93.
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Journal of VASCULAR SURGERY
Donaldson, Rosenberg, and Bucknam
13. McCabe CJ, Coleman WS, Brewster DC. The advantage of early operation for abdominal aortic aneu~sm. Arch Surg 1981; 116:1025-9. 14. Whittcmore AD, Clowes AW, Hechtman HB, Mannick JA. Aortic aneurysm repair--reduced operative mortality associated with maintenance of optimal cardiac performance. Ann Surg 1980; 192:414-21. 15. Hyde GL, Sullivan DM. Fogarty catheter tamponade of ruptured abdominal aortic aneurysms. Surg Gynecol Obstet 1982; 154:197-9. 16. Sensenig DM. Rapid control in ruptured abdominal aortic aneurysms. Arch Surg 1981; 116:1034-6.
17. Starr DS, Lawrie GM, Morris GC. Prevention of distal errs' bolism during arterial reconstruction. Am J Surg 1979; 138:764-9. 18. Bandyk DF, Florence MG, Johansen KH. Colon ischemia accompanying ruptured abdominal aortic aneurysm. J Surg Rcs 1981; 30:297-303. 19. Tilney NL, Bailey GL, Morgan AP. Sequential system failure after rupture of abdominal aortic aneurysms: An unsolved problem in postoperative care. Ann Surg 1973; 178:117-22.
LIEBIG FOUNDATION AWARD FOR VASCULAR SURGICAL RESEARCH, 1986 The Liebig Foundation announces the fifth annual competitive award of $5000 for the best essay on a problem in general surgery. The investigative work shall be: 1. Clinical and experimental research 2. Original and unpublished 3. Performed by a house officer in the United States, Canada, or Mexico with senior collaborators acting in a consultive capacity 4. Submitted in English (6 copies of typed manuscript with 6 copies of glossy prints of illustrations) Previous winners were: 1985, Kenneth A. Kesler, M.D., research fellow, Indiana University Medical Center, Indianapolis, Ind.; 1984, Kenneth Ouriel, M.D., resident, University of Rochester Medical Center, Rochester, N.Y.; 1983, C. Scott Norris, M.D., research fellow, Medical College of Virginia, Richmond, Va,; 1982, Howard P. Greisler, M.D., former resident, Columbia Presbyterian Hospital, New York, N.Y.. Furv~her inquiries may be directed to the same address to which the essays must be sent postmarked no later than December 31, 1985: Dr. Richard J. Turner Award Committee Secretary 103 Bauer Drive Oakland, N,J. 07436 USA Phone: (201) 337-6126
Rupture o f an abdominal aortic aneurysm (AAA) is a catastrophic event that without direct surgical intervention almost always results in death. Even with surgery the mortality rate remains disconcertingly high despite advances in technique, materials, and perioperative care since report o f the first successful repair o f a ruptured AAA in 19545 In the hope o f improving outcome after rupture many authors have attempted to delineate the crucial factors that affect morbidity and mortality rates. We have reviewed a consecutive series o f patients to characterize the hospital course and to identify the influence o f certain patient-determined and physician-determined variables on outcome. METHODS All patients who were operated on at Hartford Hospital between 1972 and 1983 and who were found to have a ruptured AAA were retrospectively reviewed. Rupture was defined as a defect in the aneurysmal wall that had allowed the extravasation o f a quantity o f blood. Patients who had surgery without evidence o f extravascutar hematoma and paFrom the Departments of Surgery, Hartford Hospital and the University of Connecticut School of Medicine. Reprint requests: M. C. Donaldson, M.D., Department of Surgery, University of Connecticut Health Center, Farmington, CT 06032. 564
tients who were not subjected to laparotomy for symptomatic aneurysms were excluded. Among a total o f 557 patients who underwent resection o f AAA during this period, 81 patients with proven rupture were studied. Nine staff surgeons contributed patients to this series, ranging in number contributed from one to 20. The statistical significance o f data correlations was evaluated with the chi-square test, and the predictive value o f preoperative findings was assessed by discriminant analysis. RESULTS H o s p i t a l course. The mean age o f the 81 patients treated between 1972 and 1983 was 70.5 y e a r s (range 52 to 92 years); the group consisted o f 65 men and 16 women. Associated problems included hypertension (42%), significant pulmonary disease (25%), and symptomatic coronary artery disease (23%). T w o patients had been subjected to laparotomy for other reasons less than 3 weeks before AAA rupture. At admission all but three patients (96.3%) complained o f pain; 70% had some form o f back pain and 58% abdominal pain (Table I). Fainting (30%) and vomiting (22%) were also prominent. Physical examination at admission revealed a palpable mass in 91%, abdominal tenderness in 78%, and a mean systolic blood pressure o f 91 m m Hg. Laboratory studies done prior to surgery showed a mean
Volume 2 Number 4 July 1985
Survival after ruptured abdominal aortic aneurysm
.'able I. Symptoms and findings at admission (n = 8 1 ) * Symptoms Pain Abdominal Back Fainting Vomiting Findings Mass Tenderness Blood pressure <80 mm Hg Hematocrit <38% White blood cell count > 10,000/~1 AAA seen on abdominal x-ray film
96.3158.0 70.4 29.6 22.2 91.3 77.5 41.7 42.2 79.4 74.4
*Number represents patients in the study. ~-Percentage of patients.
Table II. Preoperative blood pressure trend and operative mortality data (n = 79)* Blood pressure at administration of anesthetic >100 mm Hg <100 mm Hg
Blood pressure at admission >100 mm Hg
<100 mm Hg
Group A 18 Patients 3 (16.7%) Died Group C 6 Patients 6 (100%) Died
Group B 14 Patients 4 (28.6%) Died Group D 41 Patients 22 (53.7%) Died
*Incomplete data on two patients.
hematocrit value of 37.8% and a mean leukocyte count of 13,914/~1. A plain radiograph of the abaomen was taken in 43 patients; results were positive tor AAA in 74%. Other positive diagnostic tests included ultrasound (10), angiography (5), and peritoneal tap (1). A mean o f 31.6 hours elapsed from the time of onset of symptoms to admission to the emergency department; 31% of patients presented in 2 hours or less. Median time between admission to the hospital and entrance into the operating suite was 6.1 hours. Within 40 minutes of entering the operating room, aortic control had been obtained in half the patients. The preoperative blood pressure trend, divided into four categories, is demonstrated in Table II. Mean systolic pressure when anesthetic was administered was 91 mm Hg; in seven patients no pressure was obtainable. The mean time for surgery was 3.9 hours. Only three of the 81 ruptured aneurysms extended above the renal arteries. Thirteen patients
565
Table III. Pcriopcrative patient-determined variables (n = 81) Age* (yr) Mean Range
70.5 52-92
Sex (no.) Male Female Medical history Symptomatic heart disease Hypertension Symptomatic lung disease Peripheral vascular disease Renal insufficiency Hospital admission Mean time from symptom onset to emergency department admission (hr) Systolic blood pressure (rnm Hg) Mean Range Hematocrit* Mean Range White blood cell count Mean Range ECG changes* Operative findings Mean aneurysm size (cm) Aneurysm location (no.) Infrarenal Suprarenal Rupture site (no.) Retroperitoneal Intraperitoneal
65 16 23.0% 42.0% 25.0% 8.8% 1.2% 31.6
91.0 0-230 37.8% 24%-52% 13,914/Ixl 6000-23,000/ixl 16.1% 8.5 78 3* 71 10"
*Significant correlation with death (p < 0.06) with age >76 yr and hematocrit <30%.
(16%) were found to have an associated unruptured iliac aneurysm. Ten patients (12%) were found to have free intraperitoneal rupture and 71 had a contained retroperitoneal hematoma. Vascular control was achieved in the majority (76%) by clamping below the renal arteries but 19 patients (24%) needed suprarenal aortic occlusion for variable time intervals (mean 26 minutes). Dacron grafts (60% woven, 40% knitted) were used for all 81 patients with a sleeve graft in 31 and aortoiliac or aortofemoral bifurcation grafts in the remainder. Heparin was used almost invariably, either systemically or infused into the distal arterial tree after aortic control was achieved. Twenty-five technical complications including venous, splenic, or intestinal injury and peripheral embolization occurred in 22 patients (27%), resulting in reoperation in eight and associated with death in 13 (59.1%). Intraoperative deaths occurred in 12
Journal of VASCULAR SURGERY
566 Donaldson, Rosenberg, and Bucknam
T a b l e IV. Perioperative physician-determined variables (n = 81)
Variable
Time course Emergency department to operating room .(hr) Median Range Operating room to aortic clamping (mm) Mean Range Duration of surgery (hr) Mean Range Operative course Systolic blood pressure (mm Hg) At anesthetic administration Mean Range At aortic clamping Mean Range Suprarenal clamping (No. of patients) Duration of suprarenal clamping (min) Mean Range Technical complications* (No. of patients) Urine output~ (nil) Mean Range Total fluids at operation (ml) Mean Range Total amount of blood transfused (units) Mean Temperature of patients when leaving surgery (°F) Mean Range Administration of pressors in recovery departments (No. of patients)
Table V. Postoperative course (n = 81)
6.1 20 min to 96 hr 50.8 10-270 3.9 1-8
91.3 0-200 101.2 0-210 19 (23.5%) 26 5-75 22 (27.2%) 510 " 0-1900 7710 3200-14,000 11.1 94.6 86-100 16 (23.5%)
*Significant correlation with mortality (p < 0.05). tFourteen patients were anuric. instances (15%) with four additional deaths within the first few hours after the patients reached the recovery room. The average fluid requirement during surgery was 7.7 liters and 29% o f the patients required more than 10 liters. The mean transfusion requirement was 11.1 units and 25% o f patients needed 15 or more units o f packed cells or whole blood. The average intraoperative urine output was 510 ml; urine output was 200 ml or less in 32% of patients, and 17% were anuric. In the recovery r o o m 40% o f patients were given diuretics whereas 24% needed pressor agents. The most c o m m o n postoperative complications among the 65 patients surviving at least 1 day after
Died day of surgery Survived day of surgery ECG changes Amylase elevation Bilirubin elevations Serum creatinine elevations Ischemia of the colons Tracheal intubation >3 days* Ileus >5 days* Dialysis* Patient stay Intensive care unit (mean days) Hospital (mean days) Survived past first day after surgery Overall survival
No. ofpatients (%) 16 (19.7) 65 (80.2) 13 (20.0) 12 (18.5) 14 (21.5) 29 (44.6) 7 (10.8) 27 (41.5) 28 (43.0) 18 (27.6) 5.4 (range 0-48) 20.1 (range 0-81) 46/65 (70.7) 46/81 (56.7)
*Significant correlation with mortality (p < 0.05).
;~
surgery were tracheal intubation for more than 3 days (41%), serum creatinine elevation (45%), renal failure requiring dialysis (28%), and ileus for more than 5 days (43%). N e w cardiac ischemia or arrhythmia occurred in 20%, hyperbilirubinemia in 21%, and hyperamylasemia in 18%. Ischemia o f the colon became manifest in seven patients (11%). The length o f stay in the hospital averaged 20.1 days a m o n g the patients who survived the day o f surgery, with an average o f 5.4 days in the intensive care trait. Total hospital stay was not significantly different between patients w h o were eventually discharged and those who died. Days spent in the intensive care unit by survivors were less than half that by nonsurvivors (4.15 vs. 10.75 days). The overall mortality rate was 43.3% for the entire group o f 8J, patients and 29.3% for the 65 w h o survived the day o f surgery. Correlative analysis. Facts describing the hos- , pital course wcrc divided into two major categories depending on whether they were determined prior to medical intervention or were to some degree under the control o f physicians (Tables I I I and IV). Patientdetermined factors tested and found to correlate statistically with eventual death were age more than 76 years, hematocrit less than 30% and presence o f electrocardiographic instability at admission, and the finding ofsuprarenal extension or free peritoneal rupture o f the AAA. Neither history o f prior cardiorespiratory or renal disease nor preoperative elevations in serum creatinine or urea nitrogen could be asso- . ciated with outcome. Regarding variables under some degree o f control ,
Volume 2 Number 4 July 1985
Survival after ruptured abdominal aortic aneurysm 567
.'able VI. Surgery for abdominal aortic aneurysm 1957-1980 Interval
Unruptured (% mortality)
Ruptured (% mortality)
Total (% mortality)
1957-1971 1972-1983 Total
183 (4.9) 476 (5.0) 659 (5.0)
74 (47.3) 81 (43.2) 155 (45.2)
257 (17.1) 557 (11.1) 814 (11.8)
by the physician, a significant correlation was found between mortality rate and preoperative blood pressure trend (Table II). When systolic blood pressure could be maintained at or increased to 100 mm H g prior to the administration of anesthetic (groups A and B), there was improved survival. The presence of persistent hypotension (group D) was not so om;'lous as a downward trend in pressure (group C), which was associated with a 100% mortality rate. Time between entering the operating room and aortic clamping averaged 20 minutes in this unfortunate group, appropriately shorter than that time in all other groups. Eight of the 10 vascular, intestinal, and splenic injuries inflicted during surgery occurred in the groups who remained hypotcnsive or became hypotcnsive preoperatively. Total duration of time with blood pressure less than 100 mm H g correlated significantly with outcome. Patients in an unstable condition, defined as those who arrived at the hospital with a blood pressure less than 100 mm H g and a hematocrit less than 35%, were not taken to the operating room any sooner than ones in a stable condition, defined as those with pressures over 100 mm H g and hematocrit more than 35%. Patients in an unstable condition experienced "aore than twice the overall mortality rate (54.5%) than those in stable condition (22.2%). Patients in an unstable condition who wcrc delayed more than 30 minutes before entering the operating room experienced a 6 8 % (13 of 19) mortality rate, as opposed to a 16% (one of six) mortality rate if surgery was possible within 30 minutes of admission. In the operating room a significantly higher mortality rate was associated with technical complications, including venous, intestinal, or splenic injury and peripheral embolization. All other intraoperativc parameters were not statistically important to survival. Postoperative use of pressor agents, tracheal intubation for more than 3 days, ileus for more than 5 days, bilirubin and serum creatinine elevation, and use of dialysis all correlated statistically with mortality rates (Table V). Six of the seven patients in whom
ischemia of the colon became evident after surgery died despite an aggressive reoperative policy. These postoperative morbid events were generally consequences of the combined insults of AAA rupture and surgery, and not independent risk factors. In an effort to predict outcome from preoperative patient status, discriminant analysis was performed with patient-determined factors evident at admission to the hospital. Age was the most important discriminant of survival, followed by hematocrit and blood pressure values at admission. Combined weighting of these three factors provided accurate prediction of outcome 70% of the time. DISCUSSION Overall mortality rates after surgery to treat ruptured AAA have decreased only modestly during past years. From 1957 to 1971 the survival rate at Hartford Hospital was 52.7%, 2 compared with 56.7% between 1972 and 1983 (Table V1). Except in a few reports, a-s other series have shown a similar relative stagnation of progress, 6qa all the more striking in view of the low mortality rates of 0% to 4.2% reported for elective AAA resection. 1°-14In addition to these elective resections, our mortality rate of 5.0% includes those patients exhibiting symptoms and undergoing surgery on an emergency basis who were found at operation not to have AAA rupture. Clearly, efforts to detect and treat AAAs before catastrophe must be maintained and expanded. An aggressive elective policy is justifiable for elderly patients who have a good prognosis despite the presence of an aneurysm as well as for younger patients with relatively small AAAs (i.e., 4 tO 5 cm). Once the AAA has ruptured, the surgical team is placed at a tactical disadvantage, trying to control a lethal disease process often already well advanced by the time the patient enters the hospital. Indeed, eventual outcome after surgery is strongly tied to factors determined before medical intervention. Age of the patient and hematocrit and blood pressure values present at admission heavily influenced subsequent events in the hospital in our series. These data pre-
568 Donaldson, Rosenberg, and Bucknam
dicted outcome with 70% accuracy for any given patient by a computer-derived discriminant algorithm. Although these variables are important to survival, their predictability is not precise enough for such a statistical formula to be applicable in medical triage. The most crucial step determined by the physician in therapy for ruptured AAA is definitive control of ongoing or recurrent blood loss through the aneurysm wall. Although many patients who survive to reach the hospital have a contained retroperitoneal hematoma that is relatively stable, the likelihood of a sudden increase in bleeding with deepening hypvolemia is totally unpredictable. In our series all patients who were in stable condition initially and who experienced a precipitous drop in blood pressure from rapid bleeding died. Patients whose pressures could be maintained or raised to a level more than 100 mm H g did relatively well and were presumably not bleeding or were bleeding at very slow rates during the immediate preoperative period. Even patients in whom hypotension at admission could not be corrected prior to surgery, presumably with moderate ongoing bleeding, fared better than those patients in stable condition initially who suddenly deteriorated. Because of the unpredictability of continued leaking, undue delay before surgical intervention can be expected to increase the chance of having to operate urgently under suboptimal technical conditions to control sudden hemodynamic deterioration; some of our patients might have survived with more prompt surgery. The patient's stable condition is not a reason to relax; once the diagnosis seems clear and resuscitation has been initiated, the operating room team should move, regardless of whether the patient is still hypotensive. Fifty-five of our patients entered the hospital in a hypotensive state, and 41 of them were still hypotensive at the time of administration of anesthetic despite preoperative efforts to improve their blood volume status. The duration of hypotension correlated significantly with outcome with the criterion of 100 mm H g or less to define the hypotensive group. A better indication of the adequacy of peripheral peffusion, such as pH, might be a more useful predictor of outcome than blood pressure. It is probable, although undocumented by our series, that blood volume repletion sufficient to raise blood pressure to normal levels will precipitate recurrent bleeding, and that stable relative hypotension with improved perfusion should be the modest goal of preoperative fluid resuscitation efforts. Ultimate con-
Journal of VASCULAR SURGERY
trol can occur only with aortic clamping, and fluk, I resuscitation must be regarded as a most tenuous adjunct as the diagnosis is being established and the surgical team is being mobilized. It was surprising to us to find unexpectedly prolonged time intervals between admission of the patient to the hospital and transport to the operating room. Some of this time was spent confirming the diagnosis, without which timely and useful intervention is impossible. A number of patients in our series undoubtedly suffered from either misdiagnosis or delayed diagnosis. The clinical picture can be misleading, and the classic triad of sudden severe back or abdominal pain, tender pulsatile abdominal mass, and hypotension was present in only 47% of our patients at admission. Atypical pain in the hip, groin, or thigh might occur. Hypotension is often abser" '~ and a mass or tenderness may not be readily detectable, particularly in an unresponsive subject. The presence of any part of the classic triad should be sufficient reason to assume a ruptured AAA may be present until proven otherwise, especially in a patient with a known previous aneurysm. Simple radiographs, ultrasound, and/or CT scans are rapid and often fruitful objective tests to confirm the presence of an AAA, with extramural rupture sometimes evident. However, prompt surgical exploration should not be delayed in order to pursue additional diagnostic workup; once the diagnosis is even suspected, mobilization of the operating team should be started. In a comparison of the four patient groups categorized according to the preoperative blood pressure course, there was no difference in time between admission and transport to the operating room. However, there was an appropriate decrease in tim ~, before aortic clamping in the two groups with hypotension at the time of anesthctic administration. These two groups had the highest technical complication and mortality rates. Technical complications, including venous, intestinal, and splenic injury and embolization, correlated significantly with survival for the entire series. O f i9 patients who died in the postoperative period, 13 (68%) had suffered a technical complication, whereas such mishaps occurred in only seven (15 %) of the 46 eventual survivors. It is reasonable to assume that technical complications may have contributed independently to the mortality rate and that it might be possible for physicians to reduce deaths by working to reduce the complication rate. A higher incidence of complications found in pa-
Volume 2 Number 4 July 1985
" dents who were hypotensive at the time of administration of anesthetic and in whom there is a necessity for rapid and sometimes less precise aortic exposure and control suggests that obtaining aortic occlusion by alternate swift and atraumatic means might be fruitful. Others have recommended temporary thoracic aortic clamping via a left thoracotomy, supraceliac clamping through the gastrohepatic ligament, or balloon occlusion via a peripheral artery. 4,1s Blunt suprarenal compression with a fist or occluding device5 may also allow more careful dissection of the aneurysm neck as may low incision of the aneurysm with introduction of an occluding balloon to effect control before mobilizing the duodenum and left renal vein) 6 Because temporary suprarenal clamping by any technique may increase .~orbidity and mortality rates, it should probably be reserved for patients who arc in an unstable condition and in whom the risk of visceral injury during hasty infrarenal aortic clamping is judged to be high. There are clearly enough options available to provide rapid aortic control without inflicting mortal damage to important structures. Peripheral thromboembolization occurred in 11 patients. It was recognized and treated at the time of aneurysm repair in eight instances with four deaths (50%) and treated by repeat surgery later in three instances with two associated deaths (67%). It may be possible to avoid emboli by careful handling of the aneurysm and application of distal clamps first where possible, ~7 and to minimize the effects of emboli by routine use of balloon thromboembolectomy through the distal anastomosis at the time of aneurysm repair. Heparin was used almost invariably after ~ortic control had been obtained. Ischemia of the colon was recognized in seven patients during the early postoperative period, with six associated deaths (86%). It is unclear how many of these patients suffered a temporary ischemic insult during the period of preoperative hypotension and aortic cross-clamping and how many lost arterial supply as a result of aneurysm resection) 8 Eventual death aftcr surgery correlated statistically with each indication of organ failure, as expected, 19 except for elcvation of serum amylase. It is interesting that the number of days spent in intensive car~: for nonsurvivors was more than twice that for survivors, which is only one index of the greater costs associated with patients who eventually died. The course of the 19 deaths during the postoperative period was largely determined by preoperative events,
Survival after ruptured abdominal aortic aneurysm 569
and aggressive supportive measures were only partly capable of improving the outcome. Although the opportunities for saving lives are probably less in the postoperative phase than in any other stage of the disease, efforts to detect and treat complications of rupture and surgery undoubtedly made a difference to some patients. This series has again demonstrated the undesirability of being forced to treat an AAA after it has ruptured rather than electively. Although much of the eventual outcome after rupture may be determined by factors out of the physician's control, there are a number of points of impact in which additional effort might be rewarded. Early diagnosis during the initial fluid resuscitation followed by prompt, technically flawless aortic repair are the goals of management. Thirty years after the first repair of a ruptured AAA, these goals remain elusive and additional progress can be expected only with continued attempts to analyze and improve current practice. REFERENCES 1. Gerbode F. Ruptured aortic aneurysm--a surgical emergency. Surg Gynecol Obstet 1954; 98:759. 2. Bucknam CA, Deren MM, Donovan TJ, Low HBG. Abdominal aortic aneurysms at Hartford Hospital 1956-1971. Hartford Hosp Bull 1972; 27:124-8. 3. Lawrie GM, Morris }'r GC, Crawford ES, Howell JF~ Whisennand HH, Badami JP, Storey SS, Starr DS. Improved resuits of operation for ruptured abdominal aortic aneurysms. Surgery 1979; 85:483-8. 4. Lawrie GM, Crawford ES, Morris GC, Howell JF. Progress in the treatment of ruptured abdominal aortic aneurysms. World J Surg 1980; 4:653-60. 5. Mulherin JL, Edwards WH. Improved survival after ruptured abdominal aortic aneurysm. South Med J 1980; 73:986-9. 6. Gaylis H, Kessler E. Ruptured aortic aneurysms. Surgery 1980; 87:300-4. 7. Ottinger LW. Ruptured arteriosclerotic aneurysms of the abdominal aorta. JAMA 1975; 233:147-50. 8. Hoffman M, Avellone JC, Plecha FR, Rhodes RS, Donovan DL, Beven EG, DePalma RG, Frisch IA. Operation for ruptured abdominal aortic aneurysms: A community-wide expericnce. Surgery 1982; 91:597-602. 9. Shumacker HB, Barnes DL, King H. Ruptured abdominal aortic aneurysms. Ann Surg 1973; 177:772-9. 10. Hicks GL, Easdand MW, DeWeese JA, May AG, Rob CG. Survival improvement following aortic aneurysm repair. Ann Surg 1975; 181:863-9. 11. Crawford ES, Saleh SA, Babb JW, Glacser DH, Vaccaro PS, Silvers A. Infrarenal abdominal aortic aneurysm--factors influencing survival after operation performed over a 25-year period. Ann Surg 1981; 193:699-708. 12. Soreide O, Lillestol J, Christensen O, Grimsgaard C, Myhre HO, Solheim K, Trippestad A. Abdominal aortic aneurysms: Survival analysis of four hundred thirty-four patients. Surgery 1982; 91:]88-93.
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Journal of VASCULAR SURGERY
Donaldson, Rosenberg, and Bucknam
13. McCabe CJ, Coleman WS, Brewster DC. The advantage of early operation for abdominal aortic aneu~sm. Arch Surg 1981; 116:1025-9. 14. Whittcmore AD, Clowes AW, Hechtman HB, Mannick JA. Aortic aneurysm repair--reduced operative mortality associated with maintenance of optimal cardiac performance. Ann Surg 1980; 192:414-21. 15. Hyde GL, Sullivan DM. Fogarty catheter tamponade of ruptured abdominal aortic aneurysms. Surg Gynecol Obstet 1982; 154:197-9. 16. Sensenig DM. Rapid control in ruptured abdominal aortic aneurysms. Arch Surg 1981; 116:1034-6.
17. Starr DS, Lawrie GM, Morris GC. Prevention of distal errs' bolism during arterial reconstruction. Am J Surg 1979; 138:764-9. 18. Bandyk DF, Florence MG, Johansen KH. Colon ischemia accompanying ruptured abdominal aortic aneurysm. J Surg Rcs 1981; 30:297-303. 19. Tilney NL, Bailey GL, Morgan AP. Sequential system failure after rupture of abdominal aortic aneurysms: An unsolved problem in postoperative care. Ann Surg 1973; 178:117-22.
LIEBIG FOUNDATION AWARD FOR VASCULAR SURGICAL RESEARCH, 1986 The Liebig Foundation announces the fifth annual competitive award of $5000 for the best essay on a problem in general surgery. The investigative work shall be: 1. Clinical and experimental research 2. Original and unpublished 3. Performed by a house officer in the United States, Canada, or Mexico with senior collaborators acting in a consultive capacity 4. Submitted in English (6 copies of typed manuscript with 6 copies of glossy prints of illustrations) Previous winners were: 1985, Kenneth A. Kesler, M.D., research fellow, Indiana University Medical Center, Indianapolis, Ind.; 1984, Kenneth Ouriel, M.D., resident, University of Rochester Medical Center, Rochester, N.Y.; 1983, C. Scott Norris, M.D., research fellow, Medical College of Virginia, Richmond, Va,; 1982, Howard P. Greisler, M.D., former resident, Columbia Presbyterian Hospital, New York, N.Y.. Furv~her inquiries may be directed to the same address to which the essays must be sent postmarked no later than December 31, 1985: Dr. Richard J. Turner Award Committee Secretary 103 Bauer Drive Oakland, N,J. 07436 USA Phone: (201) 337-6126